Murat Sereflican

Comparison of dexmedetomidine and midazolam for monitored anesthesia care combined with tramadol via patient-controlled analgesia in endoscopic nasal surgery: A prospective, randomized, double-blind, clinical study

UNLABELLED Abstract. BACKGROUND Monitored anesthesia care (MAC) may be applied for septoplasty or endoscopic sinus surgery in which an adequate sedation and analgesia without respiratory depression are desired for comfort of both the patient and the surgeon. Several combinations with different agents have been used for this purpose in these patients. However, analgesic properties for these agents have not been reported. OBJECTIVE The aim of this study was to investigate the analgesic and sedative effects of dexmedetomidine or midazolam infusion combined with tramadol that was used via patient-controlled analgesia (PCA), and to document the effects of these drugs on early cognitive functions. METHODS This prospective, randomized, double-blind, clinical study enrolled patients undergoing septoplasty or endoscopic sinus surgery at the Abant Izzet Baysal University Hospital, Bolu, Turkey, between February and September 2006. Patients were randomly allocated in a 1:1 ratio into 1 of 2 groups: the dexmedetomidine group (group D) patients received IV dexmedetomidine 1 μg/kg for 10 minutes followed by continuous infusion of 0.5 μg/kg · h(-1); and the midazolam group (group M) patients were administered a loading dose of IV midazolam 40 μg/kg for 10 minutes followed by infusion at the rate of 50 μg/kg · h(-1). A 1-minute bolus dose of IV tramadol (1.5 mg/kg) was administered in both groups 10 minutes after the administration of the primary drug, and continued via infusion using a PCA device. After baseline measurements, systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), oxygen saturation, and rate of respiration were recorded after the loading dose of study drug, after the bolus tramadol dose, at 10-minute intervals during the operation, and twice in the recovery rooms; 5 minutes after arrival and 5 minutes before discharge. Verbal rating score (VRS) and Ramsay sedation score were determined at baseline (after surgery was started), every 10 minutes thereafter until the end of the operation, and 2 times during recovery. All patients were assessed with the Wechsler Memory Scale-Revised at baseline (preoperatively) and 4 hours after the operation. RESULTS Seventy patients were enrolled in the study and randomly assigned to 1 of 2 groups: group D (sex, male/female, 23/12; mean [SEM] age, 32.53 [2.07] years; mean [SEM] weight, 73.03 [2.41] kg) or group M (sex, male/female, 21/14; mean [SEM] age, 34.43 [1.83] years; mean [SEM] weight, 67.90 [2.32] kg). All hemodynamic parameters (SAP, DAP, MAP, HR) were significantly higher in group M compared with group D from the onset of the surgery to discharge time (P < 0.05). Pain and sedation scores were similar in both groups, but the amount of PCA-administered rescue tramadol was significantly higher in group M (P = 0.001). A higher, though not statistically significant, prevalence of adverse events (ie, hypotension, bradycardia, and perioperative nausea and vomiting) were observed in group D. Postoperative logical verbal memory and digit span values were significantly higher in group D when compared with group M (P < 0.05). Postoperative digit span and visual reproduction scores were significantly higher than preoperative values in group D (P < 0.05). Postoperative personality functioning scores were significantly higher than preoperative values in group M (P < 0.05). CONCLUSIONS Based on VRS, Ramsay sedation scores, and surgeon and anesthesiologist satisfaction scores, dexmedetomidine or midazolam combined with tramadol PCA provided adequate analgesia and sedation in these adult patients undergoing septoplasty or endoscopic sinus surgery with MAC. A significantly larger amount of rescue tramadol was used by group M, suggesting that a better analgesic effect was achieved with dexmedetomidine.

The histopathological and electrophysiological effects of thymoquinone and methylprednisolone in a rabbit traumatic facial nerve paralysis model

OBJECTIVE We aimed to determine the effects of methylprednisolone and thymoquinone on nerve healing in a traumatic facial nerve paralysis animal model. SUBJECTS AND METHODS Twenty-four rabbits were randomly divided into 4 groups: group I: control group received no medication and no trauma; group II: sham group received no medication after facial nerve trauma group III: 5mg/kg/day thymoquinone administered; group IV: 1mg/kg/day methylprednisolone administered. An initial electrophysiological assessment was performed in all the animals. The buccal branch of the facial nerve was then clipped to form a traumatic facial paralysis model. The drugs were administered for two weeks once a day. At the end of the second month, the electrophysiological assessments were performed and the distal part of the traumatic facial nerve were dissected and examined under light microscopy. RESULTS Best nerve regeneration was observed in the control and the thymoquinone groups, respectively, whereas the weakest regeneration was determined in the sham group. Thymoquinone and methylprednisolone significantly increased nerve recovery, as measured by histopathological scores and electrophysiological assessment. In the thymoquinone group, due to postoperative amplitude, axon diameter and thickness of myelin sheath values were significantly further increased nerve regeneration compared to that of the methylprednisolone group and these values were close to those of the values of the control group. CONCLUSION Thymoquinone was slightly better than methylprednisolone for functional nerve recovery. The neuroprotective effect of thymoquinone was attributed to its antioxidant and anti-inflammatory effects. Thymoquinone can have a new treatment option to ameliorate the nerve injury.

In reference to Snoring and carotid artery intima-media thickness.

We read with great interest the recent article by Deeb et al. regarding the relationship that exists between snoring and intima-media thickness (IMT) of the carotid arteries. The authors very clearly discussed the relationship between primary snoring and IMT of the carotid arteries. They concluded that the relationship between increased carotid IMT and serious health conditions, and nonapneic snoring may be a precursor to changes of the carotid artery. In addition to their fluent discussion, we aim to emphasize the possible other effective mechanism of snoring and carotid artery IMT: the contribution of autonomic nervous system function. Previous studies clearly showed that obstructive sleep apnea syndrome (OSAS) and snoring lead to nocturnal intermittent hypoxia, increased negative intrathoracic pressure, increased sympathetic nervous system activity, and elevation of reactive oxygen radicals. All of these factors cause vascular atherosclerosis. Previously, we showed that a close relationship between OSAS and impaired autonomic nervous system function is detected by different methods in OSAS patients without coronary artery diseases or other comorbidities. Together with this, nocturnal intermittent hypoxiarelated impairment in autonomic nervous system function is thought to play a central role in the risk of cardiovascular death. Several studies in the literature showed that IMT of the carotid artery and impaired cardiac autonomic function are inversely related. Galetta et al. clearly illustrated the relationship between the imbalance of cardiac autonomic activity and the development of carotid artery IMT. They discussed that the imbalance of cardiac autonomic activity plays an important role in the development of atherosclerosis through three possible mechanisms: increased heart rate with a consequent increase in oxygen consumption, increased shear stress leading to plaque fissure, and enhanced atherosclerosis through increased macrophage low-density lipoprotein cholesterol oxidation. We believe that the effect of snoring and IMT on autonomic nervous system function may play a role in the results described in article by Deeb et al. We hope that the above-mentioned items will add to the value of their well-written article regarding the relationship that exists between snoring and IMT of the carotid arteries.

A pediatric case of anesthesia mumps after general anesthesia

Sir/Madam, We would like to report an 8-year-old child with swelling of the right parotid gland after general anesthesia. He weighed 18 kg and underwent adenoidectomy and bilateral tympanostomy tube insertion operation. Preoperatively, he was normal and he also had no other medical problem. Anesthesia induction was performed with 2 mg/kg of propofol, 1 mcg/kg of fentanyl, and 0.5 mg/kg of rocuronium. After endotracheal intubation, maintenance of anesthesia was achieved with sevoflurane (2-3 vol%) in 50% O2 and 50% air. The surgical procedure lasted for 35 min. The patient was extubated without any problems at the end of the surgery. After the extubation period, we noticed a painless swelling on the right parotid gland extending the angle of the mandible [Figures ​[Figures11 and ​and2].2]. There was no sign of inflammation. The right parotid gland swelling disappeared in the next 24 h without any sequelae. Figure 1 Adenoid face of patient and swelling of right parotid gland Figure 2 Swelling of right parotid gland Acute transient swelling of the parotid gland related to anesthesia, defined as “anesthesia mumps,” is a rare complication. It is a benign and noninfectious complication.[1] This usually occurs immediately after surgery and resolves spontaneously over a period of a few hours to a few days without any known sequelae.[2] It was more rarely seen in the pediatric population compared to adults. Although the exact mechanism of anesthesia mumps is not fully explained, different explanations have been suggested including obstruction of Wharton or Stensen ducts from patient positioning and endotracheal tube placement, positive pressure ventilation during and increased pressure in the oral cavity, and thickened oral secretions secondary to salivary stasis.[3] We thought that the clinical picture in our case may have resulted from intraoral pressure increase by mask ventilation or from obstruction of ducts due to head positioning during bilateral tympanostomy tube insertion. Our patient had an adenoid face (a narrow upper dental arch, increased anterior face height, a steep mandibular plane angle, and a retrognathic mandible). Manual ventilation on mask was not comfortable due to poorly fitting mask during the induction. Also, the patient had a relative microgratia. On the other hand, tympanostomy tube insertion was made when the head rotated to the left side and right side. Anesthesia mumps usually resolves spontaneously over a period without any treatment. In some cases, hydration and warm compresses may be helpful in relieving the symptoms.[2,4] In our case, we managed the swelling conservatively by the advice of otolaryngology clinic. The swelling decreased and resolved completely in 24 h. Additionally, there was no radiologic image for this patient. The swelling of the parotid gland resolved gradually and also, the otolaryngologists did not anticipate any other pathology due to signs of swelling. We did not want to perform an x-ray examination of this child patient for benign swelling. In conclusion, anesthesia mumps may occur immediately after general anesthesia in pediatric patients and they fully recover. Also, we hope that the reporting of such pediatric cases would increase the awareness among anesthesiologists regarding this benign complication.

An evaluation on the role of MPV on idiopathic sudden hearing loss etiology.

With the great interest, we have read the study in your journal entitled ‘‘Increased levels of mean platelet volume: a possible relationship with idiopathic sudden hearing loss’’ by Ulu et al. [1]. We would like to make some comments about this study. In recent years, the number of the studies, which state the increase of mean platelet volume (MPV), plays a role on the etiopathogenesis of many illnesses, gradually increases [2, 3]. In the near future, some studies, which investigate the relations between MPV and idiopathic sudden hearing loss (ISHL) about which there are too few publications, have been reported [1, 4]. Although a good number of assertive results have been announced in these studies, sufficient usage area of MPV value measurement has not occurred in the follow-up and treatment of patients clinically as there is no fully standardized method of this parameter. Some of the factors that affect the standardization of MPV measurement are the environment of blood-taking, type and amount of anticoagulant in the blood collection tube, the duration between blood-taking and examination, being 7–10 days of thrombocytes lifetime, the device of examination and the calibration time of the device. It has been reported that there are measurement differences up to 40 % even among the devices in the studies, in which different devices were used [5, 6]. In your study, the fact that MPV value has been found higher in the patients with ISHL in proportion as control group is agreeable to literature information. In contrast with your study, Karli et al. [4] found no difference between patient group with SHL and control group. Besides this, it has not been stated how much healing rate was and whether MPV value was measured or not after treatment according to audiometric examinatorial results applied on the patients in the first month after the medical treatment in which prednisone (1 mg/kg/day) was given during 15 days. As a result of this, we do not think that the etiology of ISHL can be explained with thrombotic/ischemic events. Moreover, if we consider that MPV measurement may be affected from many factors stated above, we think it is an assertive statement that this value can be used as an instructive marker for ISHL. While hemoglobin and thrombocyte count values between control and working groups were stated in the study, the values of preoperative and postoperative patient groups and the changes in these values were not stated. As a consequence, even if MPV has been associated with many illnesses recently, it does not seem possible for now to associate these results with disease etiopathogenesis in the limited studies that state MPV value as high in the patients with ISHL. To make better comments about this issue, we think that the results should be presented by evaluating pre and post of treatment, on more test subjects and in longer term. This comment refers to the article available at doi:10.1007/s00405-013-2348-9.

Giant Chondroid Syringoma of the Breast

*Department of Dermatology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Radiology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Chest Disease, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey; Department of Otorhinolaryngology, Bolu Koroglu State Hospital, Bolu, Turkey; Department of Pathology, Medical Faculty, Abant Izzet Baysal University, Bolu, Turkey